Addressing inequality of access to medical schools 

There is a strong argument for access programmes that provide us with a more diverse medical workforce 

Watch them with nervous awe as they march the hospital corridors, wielding effervescent smiles and 20 conference abstracts already. Wilt before their cheerful deference and breathless requests for more bedside tutorials. Crumple into insignificance when you learn about the non-profit that they co-directed before doing medicine and the for-profit that they run in their spare time between 1-3am. You’ve witnessed an American medical student in the wild.

While enthusiasm and energy can be common in medical students everywhere, including Ireland, they’re a little different to the equivalents that I encounter in America. It’s worth considering whether our criteria for selecting students are responsible for this and which system is doing a better job.

In America, the blend of a hypercompetitive population, the social cachet of a career as a doctor, and high salaries leads to intense demand for the limited places in medical schools. Universities are therefore constantly seeking new ways to pick the best prospects in a process that can be closer to splitting hairs than separating the wheat from the chaff. Grand personal statements, letters of recommendation from pillars of society, lavish extracurricular records, and voluntary work are all on the menu, alongside unblemished CVs as undergraduates. This hothousing begins in the teenage years by the most pointy-elbowed of parents.

All these activities, alongside the interview prep and coaching, represent a stark challenge for poorer families, although it’s mitigated somewhat by more substantial scholarships than in Europe.

The Irish approach, by contrast, is not as monolithic as it often seems. Alongside the standard undergraduate route (based on combined Leaving Cert and HPAT [Health Professions Admission Test] results), there is graduate-entry (undergraduate and GAMSAT [Graduate Medical School Admissions Test] results) and mature-entry (based on more holistic criteria, including educational experience, work, voluntary experience, and statement of interest).

But despite the breadth of options, this system is scorned for many reasons. Those from wealthier backgrounds are consistently over-represented. Most candidates are selected based on exam results rather than a broader set of characteristics. And even the tests that claim to depend on innate ability – HPAT – can be gamed. But is there a better alternative?

In my mind, the best system would achieve two things. One is to choose candidates who turn out to be excellent doctors. The second is to achieve a mix of students who are broadly representative of Irish society.

A first challenge in this situation is to identify what would represent a ‘better doctor’. Is it better scores on medical exams, which are at least measurable and comparable, but a pretty narrow picture of a person? Dropout rates from medicine? Patient ratings of their doctor?

I don’t think the American approach would be a step forward. The downsides are clear: Yet more financial hurdles and yet more instances where subjective impressions – interviews and personal statements – can trump impartial tests. The upsides are more fuzzy. Does the US system produce more competent and balanced doctors than the rest of the world? While I have worked with many excellent doctors here, nobody knows if they are outperforming their colleagues in Ireland, the UK, or Australia.

Most of the research regarding student selection has used performance in medical school exams as a measure of success. While there are different findings, one conclusion from the Netherlands is that integrated selection tools featuring a composite of different criteria (secondary school results, extracurricular activity, entrance exams, and personal statement) seem to predict well for later results. Our use of the HPAT as an isolated add-on to the Leaving Cert does not quite match up to this.

What, then, about increasing diversity? It is not clear to me that university selection criteria can ‘fix’ the ample inequalities that exist in society and our education system before the age of 18. A study in Denmark that tested the use of ‘attribute-based’ admission to build a more diverse population found that it made no difference. The Irish HPAT appears to have made no change to the social background of medical students. Approaches that actively recruit students from under-represented backgrounds via a parallel pathway (like the Trinity Access Programme) seem more likely to succeed. An important part of their effectiveness is that they start early in secondary schools to get the best results. There is a strong argument for access programmes that seek to increase enrolment from under-served communities, giving us a medical workforce that looks like modern Ireland and which recognises the head start many others get in life. But if your goal is simply ‘produce good doctors’, there is little evidence that the HPAT is improving things – it’s just a financial and social obstacle. It should either be part of a holistic strategy, like in the Dutch example, or ditched altogether.